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Continuous intrathecal baclofen infusion for spasticity of cerebral origin.

OBJECTIVE: To determine if continuous intrathecal baclofen infusion (CIBI) would provide continuous relief of spasticity in patients with spasticity of cerebral origin, especially children with cerebral palsy. DESIGN: Prospective, unblinded trial, before and after CIBI. SETTING: Children's Hospital of Pittsburgh (Pa). PATIENTS: Thirty-seven patients, 5 to 27 years of age, with spasticity of cerebral origin. INTERVENTION: Continuous intrathecal baclofen infusion for 3 to 48 months. MAIN OUTCOME MEASURES: Muscle tone, range of motion, upper extremity timed tasks, activities of daily living (ADLs). RESULTS: Six and 12 months after CIBI, muscle tone was significantly decreased in the upper (P = .04) and lower (P = .001) extremities. There was a significant relationship between baclofen dosage and muscle tone in the upper (P = .02) and lower (P = .001) extremities. Hamstring motion, upper extremity function, and ADLs were significantly improved in 25 patients who were capable of self-care. CONCLUSION: Spasticity of cerebral origin can be effectively treated with CIBI. Because baclofen dosages can be titrated for the desired clinical response, CIBI is particularly useful for patients who need some spasticity to stand and ambulate.

Adolescent↗

Gender differences in active musculoskeletal stiffness. Part I. Quantification in controlled measurements of knee joint dynamics.

Active females demonstrate increased risk for musculoskeletal injuries relative to equivalently-trained males. Although gender differences in factors such as passive laxity, skeletal geometry and kinematics have been examined, the effect of gender on active muscle stiffness has not been reported. Stiffness of the active quadriceps and hamstrings musculature were recorded during isometric knee flexion and extension exertions from twelve male and eleven female subjects. A second-order biomechanical model of joint dynamics was used to quantify stiffness from the transient motion response to an angular perturbation of the lower-leg. Female subjects demonstrated reduced active stiffness relative to male subjects at all torque levels, with levels 56-73% of the males. Effective stiffness increased linearly with the torque load, with stiffness increasing at a rate of 3.3 Nm/rad per unit of knee moment in knee flexion exertions (hamstrings) and 6.6 Nm/rad per unit of knee moment extension exertions (quadriceps). To account for gender differences in applied moment associated with leg mass, regressions analyses were completed that demonstrated a gender difference in the slope of stiffness-versus-knee moment relation. Further research is necessary to identify the cause of the observed biomechanical difference and implications for controlling injury.

Adult↗

The influence of initial posture on the sit-to-stand movement.

Head movements, ground reaction forces and electromyographic activity of selected muscles were recorded simultaneously from two subjects as they performed the sit-to-stand manouevre under a variety of conditions. The influence of initial leg posture on the magnitude of the various parameters under investigation was examined first. A preferred initial leg posture resulted in smaller magnitudes of head movement and ground reaction forces. EMG activity in some muscles, trapezius and erector spinae, decreased, while in others, quadriceps and hamstrings, it increased in the preferred leg posture. The decreases seen correlate with reductions in head movement observed. The effect of inhibiting habitual postural adjustments of the head and neck, by comparing "free" and "guided" movements was also examined. In guided movements there are significant reductions in head movement, ground reaction forces and EMG activity in trapezius, sternomastoid and erector spinae. It would appear that both initial leg posture and the abolition of habitual postural adjustment have a profound influence on the efficiency of the sit-to-stand manouevre. This preliminary study high-lights the practical importance of head posture in the diagnosis and treatment of movement disorders, as well as in movement education.

Humans↗

Isokinetic rehabilitation after arthroscopic meniscectomy.

The aim of this study was to assess the effects in humans of early (2 weeks) and delayed (6 weeks) isokinetic strength training in the recovery of muscle strength following an arthroscopic partial meniscectomy. The peak torque developed in the quadriceps and hamstrings and the torque developed at a knee angle of 1.05 rad were evaluated in 16 subjects, pre-operatively (pre-op), and 2, 6, and 10 weeks post-operatively (post-op), on an isokinetic device at four different velocities (1.05, 2.09, 3.14, and 4.19 rad.s-1). The fatigue characteristics of the muscles were evaluated by having the subject perform 15 maximal contractions at 3.14 rad.s-1. Training was done on the same device (three times a week for 1-2 months), beginning either 2 or 6 weeks post-op. A repeated measures analysis of variance demonstrated a time effect but no differences between groups and no interactions. Torques developed by the knee flexors and extensors were significantly smaller 2 weeks post-op than pre-op, at all velocities tested. Torques developed in the quadriceps recovered to their pre-op values by 6 weeks, and further gained significantly in strength from 6 to 10 weeks. Quadriceps torques remained weaker than the contralateral side at 10 weeks. Hamstrings torques were either higher or similar to pre-op values by 6 weeks, and demonstrated increases from 6 to 10 weeks post-op at 1.05 and 4.19 rad.s-1 only. Total work and average power developed by the quadriceps and hamstrings during the fatigue protocol changed with time in a similar manner to torque.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Prospective study of concentric and eccentric leg muscle torques, flexibility, physical conditioning, and variation of injury rates during one season of amateur ice hockey.

Twenty-three male ice hockey players in a third division amateur ice hockey team were prospectively studied during the 1987-1988 season. O2 uptake, muscle flexibility, and isokinetic concentric and eccentric leg muscle strength were measured before and after the season. All injuries were recorded by one and the same physician attending all the games: 68 injuries occurred altogether but only six of these led to absence from training or matches. O2 uptake and muscle flexibility were unchanged during the season, but a significant drop of both concentric and eccentric quadriceps and hamstring torques occurred in spite of the fact that the team played two games and trained twice per week during the entire season. No correlation between the fall in muscle strength and the injury rate was found. Although many injuries occur in ice hockey, the majority are minor ones that do not lead to absence from playing.

Adult↗

Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts.

We report a prospective series evaluating the incidence and degree of tunnel widening in a well-matched series of patients receiving a hamstring or patella tendon graft for anterior cruciate ligament (ACL) deficiency. We correlated tunnel widening with clinical factors, knee scores, KT-1000 and isokinetic muscle strength to determine the clinical significance of this finding. Seventy-three patients at least 12 months post-ACL reconstruction were evaluated. Thirty-eight patients had received a doubled semitendinous and gracilis graft and 35 a bone-patella tendon-bone graft. All patients underwent a similar endoscopic procedure and accelerated postoperative rehabilitation. Tunnel widening was determined using standardized anteroposterior (AP) and lateral X-rays adjusted for magnification. A limited series of MRIs was performed to validate these measurements. There was a significant difference in the degree of tunnel widening between the two groups. The mean increase in femoral tunnel area in the hamstring group was 100.4% compared with a decrease of 25% in the patella tendon group (P = < 0.0001). In the tibial tunnel the mean increase in the hamstring group was 73.9% compared with a decrease of 2.1% in the patella tendon group (P = < 0.0001). The MRIs validated the plain film measurements. Tunnel widening did not correlate with the clinical findings, knee scores, KT-1000 or isokinetic muscle strength. Tunnel widening is marked in the hamstring group. Tunnel widening does not correlate with instability or a poor clinical outcome in the short term. The long-term implications of this finding are still to be determined.

Adult↗

Relationship of skeletal muscle mass, muscle strength and bone mineral density in adults with cystic fibrosis.

Few studies have investigated peripheral muscle strength and quality in patients with cystic fibrosis (CF). The present study tested the isometric and isokinetic strength of the quadriceps and hamstrings using an isokinetic dynamometer and a strength-testing chair in 25 CF adults and 25 controls. Total body and leg muscle mass were determined by dual-energy X-ray absorptiometry, and bone mineral density (BMD) was also measured. Both muscle strength and muscle mass (total body and leg) were decreased in the CF group. In both groups there was a highly significant relationship between quadriceps strength and leg muscle mass (CF, r=0.7, P=0.0002; controls, r=0.6, P=0.0013). When strength was normalized for muscle size, there was no significant difference between the two groups. Total body and leg BMD were significantly reduced in CF subjects compared with controls. However, when corrected for height, the differences disappeared. There was a significant relationship found between leg muscle mass and leg BMD. We conclude that CF adults are significantly weaker than controls. This is due to lower muscle mass, and not to a reduced force-generating capacity of the muscle, implying that there is no decrease in the quality of CF muscle. BMD is also reduced in CF subjects, and this appears to be related to shorter stature in this group.

Absorptiometry, Photon↗

Chondropathia patellae and knee muscle control. An electromyographic study.

The activity of knee-related muscles was registered via exercising on a bicycle ergometer by 17 patients with clinically diagnosed chondropathia patellae. M. quadriceps activity was shorter and the hamstring activity longer in the chondropathy group compared with a matched healthy control group. The changes in m. quadriceps occurred to an almost equal extent in lateral and medial sections. In five patients with unilateral complaints, the electromyographic changes were nevertheless noted on both sides. The study shows that chondropathia patellae involves a change in muscle control affecting not only the knee extensors but also the hamstrings. Through the changed innervation pattern the coactivation phase, i.e. the phase of simultaneous activation of knee flexors and extensors at the end of the extension phase, takes place at a higher angle of flexion. Physiotherapy should involve all knee-related muscles and should include not only isometric but also dynamic exercises.

Adult↗

Atrophy of semitzendinosus and gracilis and flexor mechanism function after hamstring tendon harvest for anterior cruciate ligament reconstruction.

The cross-sectional areas of individual knee flexors and isokinetic flexion measurements were evaluated using computed tomography in 13 patients following semitendinosus and gracilis tendon harvest for anterior cruciate ligament reconstruction. The atrophy of tendon-dissected muscles demonstrated variance with two peaks: >70% and <50%. In three patients whose semitendinosus and gracilis muscles displayed areas <50% of the contralateral area, the cross-sectional area of the entire flexor group and work at >75 degrees of knee flexion was 88.1% and 51.9%, respectively. Therefore, hamstring tendon harvest can induce atrophy of tendon-dissected muscles and decrease flexor function.

Adolescent↗

Alterations in muscle activation patterns during robotic-assisted walking.

OBJECTIVE: The goal of this study was to compare the muscle activation patterns in various major leg muscles during treadmill ambulation with those exhibited during robotic-assisted walking. BACKGROUND: Robotic devices are now being integrated into neurorehabilitation programs with promising results. The influence of these devices on altering naturally occurring muscle activation patterns utilized during walking have not been quantified. METHODS: Muscle activity measured during 60 s of walking was broken up into individual stride cycles, averaged, and normalized. The stride cycle was then broken up into seven distinct phases and the integrated muscle activity during each phase was compared between treadmill and robotic-assisted walking using a multi-factor ANOVA. RESULTS: Significant differences in the spatial and temporal muscle activation patterns were observed across various portions of the gait cycle between treadmill and robotic-assisted walking. Activity in the quadriceps and hamstrings was significantly higher during the swing phase of Lokomat walking than treadmill walking, while activity in the ankle flexor and extensor muscles was reduced throughout most of the gait cycle in the Lokomat. CONCLUSIONS: Walking within a robotic orthosis that limits the degrees of freedom of leg and pelvis movement leads to changes in naturally occurring muscle activation patterns. RELEVANCE: An understanding of how robotic-assisted walking alters muscle activation patterns is necessary clinically in order to establish baseline patterns against which subject's with neurological disorders can be compared. Furthermore, this information will guide further developments in robotic devices targeting gait training.

Adaptation, Physiological↗

Electromyography and biomechanics of a dynamic knee brace for anterior cruciate ligament deficiency.

Twelve anterior cruciate ligament (ACL)-deficient subjects performed concentric isokinetic knee extensions at maximum effort both with and without the Bledsoe Pro Shifter knee brace. Electromyogram signals from the quadriceps, hamstrings, knee angle, and the extension force were recorded and evaluated to determine the effects of such dynamic bracing on muscle activity and joint stability. High activity, or asymptomatic, subjects (n = 5) experienced no change in muscle activity, but displayed a decrease in extension force throughout the active range of the brace. Low activity, or symptomatic, subjects (n = 7) exhibited increased quadriceps activity and decreased hamstrings activity, and displayed a minor increase in force in the mid-range (80 degrees to 40 degrees flexion). These results indicate that dynamic bracing prevents quadriceps inhibition in symptomatic subjects by exerting a posteriorly directed force to the superior tibia; thus, the brace compensates externally for the absence of the ACL.

Adult↗

Length changes of the hamstrings and adductors resulting from derotational osteotomies of the femur.

Derotational osteotomies of the femur are frequently performed to treat persons with cerebral palsy who walk with excessive internal rotation of the hip. However, whether these procedures stretch or slacken the surrounding muscles appreciably is unknown. Determination of how muscle lengths are altered by derotational osteotomies is difficult because the length changes depend not only on the osteotomy site and the degree of derotation, but also on the anteversion angle of the femur and the rotational position of the hip. We have developed a three-dimensional computer simulation of derotational osteotomies, tested by anatomical experiments, to examine how femoral anteversion, hip internal rotation, and derotation affect the lengths of the semitendinosus, semimembranosus, biceps femoris long head, adductor longus, adductor brevis, and gracilis muscles. Simulation of derotational osteotomies at the intertrochanteric, subtrochanteric, or supracondylar levels decreased the origin-to-insertion lengths of the hamstrings and gracilis in our model by less than 8 mm (1.8%). Hence, the lengths of the hamstrings and gracilis are not likely to be altered substantially by these procedures. The origin-to-insertion lengths of the adductor longus and adductor brevis decreased less than 4 mm (1.9%) with subtrochanteric correction in our model, but the length of adductor brevis increased 8 mm (6.3%) with 60 degrees of intertrochanteric derotation. These muscles are also unlikely to be affected by derotational osteotomies, unless a large degree of intertrochanteric derotation is performed.

Computer Simulation↗

A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction.

BACKGROUND: Bone-patellar tendon-bone graft has been the most commonly used graft material in anterior cruciate reconstructions, but there has been increasing use of hamstring tendon grafts. However, no existing clinical studies show adequate support for the choice of one graft over the other. HYPOTHESIS: Hamstring tendons are equally as good as patellar tendon in anterior cruciate ligament reconstructions. STUDY DESIGN: Prospective randomized clinical trial. METHODS: Ninety-nine patients with laxity caused by a torn anterior cruciate ligament underwent arthroscopically assisted reconstruction with graft randomization according to their birth year. Grafts were either bone-patellar tendon-bone with metal interference screw fixation or double-looped hamstring tendons with metal plate fixation. There were no significant differences between the two groups preoperatively or at operation. Standard rehabilitation included immediate postoperative mobilization without a knee brace, protected weightbearing for 2 weeks, and return to full activity at 6 to 12 months. RESULTS: Forty-three patients in the patellar tendon group and 46 patients in the hamstring tendon group were available for clinical evaluation at a minimum of 21 months after surgery. No statistically significant differences were seen with respect to clinical and instrumented laxity testing, International Knee Documentation Committee Score ratings, isokinetic muscle torque measurements, and Kujala patellofemoral, Lysholm, and Tegner scores. CONCLUSION: Equal results were seen for patellar and hamstring tendon autograft anterior cruciate ligament reconstructions at 2 years after surgery. Both techniques seem to improve patients' performance.

Analysis of Variance↗

Muscle contributions to specific biomechanical functions do not change in forward versus backward pedaling.

Previous work had identified six biomechanical functions that need to be executed by each limb in order to produce a variety of pedaling tasks. The functions can be organized into three antagonistic pairs: an Ext/Flex pair that accelerates the foot into extension or flexion with respect to the pelvis, an Ant/Post pair that accelerates the foot anteriorly or posteriorly with respect to the pelvis, and a Plant/Dorsi pair that accelerates the foot into plantarflexion or dorsiflexion. Previous analyses of experimental data have inferred that muscles perform the same function during different pedaling tasks (e.g. forward versus backward pedaling) because the EMG timing was similar, but they did not present rigorous biomechanical analyses to assess whether a muscle performed the same biomechanical function, and if so, to what degree. Therefore, the objective of this study was to determine how individual muscles contribute to these biomechanical functions during two different motor tasks, forward and backward pedaling, through a theoretical analysis of experimental data. To achieve this objective, forward and backward pedaling simulations were generated and a mechanical energy analysis was used to examine how muscles generate, absorb or transfer energy to perform the pedaling tasks. The results showed that the muscles contributed to the same primary Biomechanical functions in both pedaling directions and that synergistic performance of certain functions effectively accelerated the crank. The gluteus maximus worked synergistically with the soleus, the hip flexors worked synergistically with the tibialis anterior, and the vasti and hamstrings functioned independently to accelerate the crank. The rectus femoris used complex biomechanical mechanisms including negative muscle work to accelerate the crank. The negative muscle work was used to transfer energy generated elsewhere (primarily from other muscles) to the pedal reaction force in order to accelerate the crank. Consistent with experimental data, a phase shift was required from those muscles contributing to the Ant/Post functions as a result of the different limb kinematics between forward and backward pedaling, although they performed the same biomechanical function. The pedaling simulations proved necessary to interpret the experimental data and identify motor control mechanisms used to accomplish specific motor tasks, as the mechanisms were often complex and not always intuitively obvious.

Bicycling↗

Changes in cortically related intermuscular coherence accompanying improvements in locomotor skills in incomplete spinal cord injury.

In human spinal cord injury, the neuronal mechanisms mediating the improvement of locomotor function in response to intensive treadmill training are not well understood. In this study, we examined if such recovery is mediated, in part, by increases in residual corticospinal drive to muscles of the leg during walking. To do this, we measured the coherence of electromyogram (EMG) activity between two antagonist muscles (intermuscular coherence), specifically at frequencies between 24 and 40 Hz, which is thought to indicate common drive to two muscles from corticospinal inputs. In 12 subjects with incomplete spinal cord injury, intermuscular coherence was measured between hamstrings and vastus lateralis EMG that was activated during walking on a motorized treadmill. Before training, appreciable coherence in the 24-40 Hz frequency band was only present in subjects with moderate volitional motor strength in their leg muscles (n = 8 subjects) compared with subjects with little or no leg muscle strength (n = 4 subjects), reconfirming that 24-40 Hz frequency coherence is likely mediated by common supraspinal inputs. After training, increases in 24-40 Hz coherence only occurred in the eight subjects with moderate leg muscle strength who also exhibited improvements in locomotor recovery as assessed by the 21 point WISCI II scale (termed responders). In contrast, development of intermuscular coherence in the 24-40 Hz frequency band did not occur in the four subjects with absent or weak muscle strength. These subjects also did not improve in their locomotor ability as reflected in unchanging WISCI II scores (termed nonresponders). Lower-frequency coherence (5-18 Hz), which is thought to contain common drive from spinal inputs, did not change in either group. In a subset of subjects that were previously assessed with transcranial magnetic stimulation (TMS) before and after training (n = 5 responders and 3 nonresponders), there was a significant and positive relationship between increases in 24-40 Hz coherence and increases in evoked muscle responses to TMS of the primary motor cortex. Taken together, increases in higher-frequency EMG coherence in subjects with residual voluntary muscle strength and its parallel relation to changes in TMS-evoked responses provides further evidence that improvements in locomotor function from treadmill training are mediated, in part, by increases in corticospinal drive to muscles of the leg during walking.

Adult↗

Sports related hamstring strains--two cases with different etiologies and injury sites.

Hamstring strains are common injuries in sports. Knowledge about their etiology and localization is, however, limited. The two cases described here both had acute hamstring strains, but the etiologies were entirely different. The sprinter was injured when running at maximal speed, whereas the hamstring strain in the dancer occurred during slow stretching. Also the anatomical localizations of the injuries clearly differed. Magnetic resonance imaging (MRI) revealed pathological changes in the distal semitendinosus muscle in the sprinter and the proximal tendon of the semimembranosus muscle in the dancer. Subjectively, both athletes severely underestimated the recovery time. These case observations suggest a possible link between etiology and localization of hamstring strains.

Adult↗

Bethlem myopathy: early-onset benign autosomal dominant myopathy with contractures. Description of two new families.

Bethlem myopathy is an apparently rare early-onset benign autosomal dominant limb-girdle myopathy with contractures of the fingers. To determine whether this disorder is unrecognized rather than rare we used muscle computerized tomography (CT) and isokinetic muscle testing and assiduously sought contractures of the fingers in relatives of two patients with the disease. CT showed that muscle impairment was mild but more diffuse than clinically apparent and showed an unexpected progressive degeneration of lumbar paravertebral muscles. The isokinetic test showed that the quadriceps was more involved that the hamstrings. In addition we found that contractures of the last four fingers progressed centripetally with age from the distal interphalangeal joints to the wrist. As a result we proved that 15 of the 21 examined subjects had the disease, 7 of them being unaware that anything was amiss. Careful examination may reveal that Bethlem myopathy is more common than is now thought.

Adolescent↗

Do oarsmen have asymmetries in the strength of their back and leg muscles?

The aim of this study was to establish whether asymmetry of the strength of the leg and trunk musculature is more prominent in rowers than in controls. Nineteen oarsmen and 20 male controls matched for age, height and body mass performed a series of isokinetic and isometric strength tests on an isokinetic dynamometer. These strength tests focused on the trunk and leg muscles. Comparisons of strength were made between and within groups for right and left symmetry patterns, hamstring: quadriceps ratios, and trunk flexor and extensor ratios. The results revealed no left and right asymmetries in either the knee extensor or flexor strength parameters (including both isometric and isokinetic measures). Knee extensor strength was significantly greater in the rowing population, but knee flexor strength was similar between the two groups. No difference was seen between the groups for the hamstring: quadriceps strength ratio. In the rowing population, stroke side had no influence on leg strength. No differences were observed in the isometric strength of the trunk flexors and extensors between groups, although EMG activity was significantly higher in the rowing population. Patterns of asymmetry of muscle activity were observed between the left and right erector spinae muscles during extension, which was significantly related to rowing side (P < 0.01). These observations could be related to the high incidence of low back pain in oarsmen.

Adult↗